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Green nephrology

Systematic review of dialysis prescriptions (use of dialysate autoflow facility)

By: Bradford Teaching Hospitals NHS Foundation Trust

£11,524 (Estimated)

3,715kg CO2e (Estimated)

A systematic review of haemodialysis prescriptions was undertaken to optimise and reduce the consumption of water, acid and bicarbonate, by using the dialysate autoflow facility on the Fresenius 5008 machine. Prior to implementation, patients dialysing using the Fresenius 5008 machine used either a 500mls/min or 800 mls/min dialysate flow. Following implementation of this change the options were 500mls/min or autoflow. Autoflow sets the dialysate flow rate to 1.5 times the blood flow rate. Therefore a patient dialysing with a 400mls/min blood flow would have a reduced dialysis fluid flow (600mls/min compared to a previous setting of 800 mls/min). This would allow the use 650g bibags rather than 900g bibags in addition to reduced consumption of water and acid concentrate.

Benefits to the environment

9% reduction in water usage for haemodialysis. 9% reduction in use of acid concentrate, use of smaller Bibags (as above).

The confirmed water saving over the first 8 months has been 95m3 per month, a total of 760m3. Total predicted annual water saving = 1140m3.

Estimated greenhouse gas savings from reduced pharmaceutical procurement (£5,760 saved on bibags + £2,880 saved on acid concentrate, per year = £8,640 total):

 = £8,640 x 0.43*

 = 3,715 kg CO2e per year

* emissions factor for pharmaceuticals, Annex 13, 2012 Guidelines to Defra / DECC's GHG Conversion Factors for Company Reporting

Cost Benefit to Trust 

Investment: staff time only.

Financial savings: direct saving in cost of Bibags of £ 5,760 p.a. plus savings in water and acid concentrates of £2,884 and £ 2,880 respectively = £11,524 per year.

Quality of care: no negative impact on dialysis adequacy.

Details of implementation

The project was implemented by a multi professional team, comprising Gary Carlisle (ward manager), David Croft (chief renal technologist) and Dr John Stoves (consultant nephrologist).

Staff were informed of the planned change and asked to identify patients who would continue to require 900g bibags (i.e. those with 500mls/min blood flow or greater than 4 hours treatment time). Staff were shown how to activate the autoflow facility. Stocks of 650g bibags were increased and a switchover date set. The patients’ dialysis adequacy for the first two months following switchover was compared with dialysis for the two months prior to switchover, to confirm that there was no reduction in the delivered dose of dialysis.

To reduce the environmental and financial and cost of haemodialysis


Joint winner of the 2013 Green Nephrology Award 

1. Autoflow facility on Fresenius 5008 dialysis machines 2. The project was inspired by a study presented at the Scottish Renal Association Meeting in 2011: A18. Use of Autoflow to determine Dialysate flow rate has the potential to reduce dialysis consumable costs but may impact on dialysis adequacy in patients with lower blood flow rates. Sean McArtney, Clinical Nurse Educator, Drew Henderson, Consultant Nephrologist, Renal Unit, Ninewells Hospital, Dundee, DD1 9SY
Gary Carlisle, Charge Nurse/ Ward Manager , Gary.Carlisle@bthft.nhs.uk

Reuse of reject water from reverse osmosis for steam production

By: University Hospitals of Bristol NHS Foundation Trust

£15,000 (Estimated)

13,836 kg CO2e / year (Estimated)

Reverse osmosis water purification for dialysis results in large quantities of water being rejected. The rejected water is currently sent to the drains, despite being perfectly clean with a slightly raised mineral content. The project will capture this reject water in the children's dialysis unit at the Bristol Royal Hospital for Children, and direct it to the sump pump at the bottom of the Queen’s building. The pump has previously been used to remove spring water and take it to the boiler house. The reject water will be taken similarly for use in the boiler house to process into steam, saving on mains water demand and reducing water supply and sewerage costs.

Benefits to the environment

Level 8 reverse osmosis plant in the Children’s Hospital currently sends 1m3 of reject water per hour to the drains. There is also 140 litres lost in sanitisation (at least once per week). 

Level 6 in the queens building is a smaller plant but will have proportional savings.

Water savings have been calculated for the main Children’s Hospital reverse osmosis plant at 8760m3 per annum. A smaller unit is estimated at half the size:  Total annual water savings = 13,140m3 (13.14 million litres).

Estimated greenhouse gas saving = 13,836 kg CO2e / year*

*Conversion factors obtained from the 2012 Guidelines to Defra / DECC's GHG Conversion Factors for Company Reporting (Annex 9, Table 9a): - water supply: 344 kg CO2e / million litres - water treatment: 709 kg CO2e / million litres

Cost Benefit to the Trust

Investment costs: £45,000 for installation of piping and pump

Savings: > £15,000 per year on mains water and sewerage

Anticipated return on investment at 5 years:  

  =  (total saving over 5y – total cost over 5y) / total cost over 5y  x  100     

=  ((£15,000 x 5) - £45,000) / £45,000 x 100 

=  67%

Details of implementation

Staff nurse Dan Speakman promoted the idea of RO water reuse through the Trust’s environmental campaign the Big Green Scheme. The initial idea was raised over two years ago. At that stage the focus for invest to save funding was on energy saving projects. Dan has persistently lobbied for the waste water to be captured despite receiving little initial support. His persistence in keeping the idea alive has paid off as water saving has more recently been recognised as an opportunity to make savings. An internal invest to save proposal (consisting of an outline of the project, the estimated costs involved and how savings would be achieved) has now been approved by Trust Finance, and installation is due to complete before the end of 2013.

The installation mainly consists of fitting pipes. A small pump will need to be fitted to get reject water from the smaller plant to join the larger RO reject water it will then be gravity fed to the sump pump that takes spring water up to the boiler house. 

Bristol Royal Hospital for Children - Dialysis Unit

To follow example of other kidney units in the Green Nephrology Network, reducing waste of high quality reject water while saving on water and sewerage costs

Green Nephrology network - drew on similar case studies from dialysis units.


Joint winner of the 2013 Green Nephrology Awards: http://sustainablehealthcare.org.uk/green-nephrology/news/2013/09/bradford-and-bristol-royal-share-2013-green-nephrology-award

Received Green Impact award for best environmental idea within University Hospitals Bristol NHS Foundation Trust in 2013.


Cost of retrofitting a greywater system was prohibitive.  Solution found was to divert the water to the boiler room to produce steam.

Daniel Speakman, Staff nurse, Dialysis Unit, Bristol Royal Hospital for Children, Daniel.Speakman@UHBristol.nhs.uk, 0117 342 8337/8311

Doncaster Renal Unit: Paperless Reporting of Routine Dialysis Haematology and Biochemistry Results

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By: Doncaster and Bassetlaw Hospitals NHS Foundation Trust

Freeing up administrative and clinical time and reducing the size and weight of notes (with resulting reduction in the costs of transport and storage and improvements in readability of the notes files). Reduction in unnecessary paper reports should reduce the risk of important results being lost, with consequent benefits to patient safety. A recent adverse incident where a microbiology report was not seen was probably in part caused by the excessive amount of unnecessary reports.

£120 (Estimated)

380kg CO2 (Estimated)

Routine monthly haemodialysis blood tests generate a very large amount of paper results (at least 20000 sheets of A4 paper per year for the approximately 160 patients on the DBH dialysis program). Such large volumes of paper result in significant clinical and administrative workload and a high risk of relevant reports being missed. All such results are reviewed electronically in the monthly dialysis MDT meetings. Given the costs and lack of utility of paper reports it was agreed with the Trust's medical director that paper reports for routine haemodialysis results could be switched off.

Details of implementationThe first step was to agree with the Trust's medical director that not having paper results did not create a risk to patient safety or a medico-legal problem. Once this had been agreed, the Medical Records department were informed to ensure that a record is kept of which notes are affected and what results are not being filed on paper.

The pathology IT manager assigned location codes to each dialysis unit and, in March 2012, set the pathology system to paperless reporting of haematology and biochemistry reports for these locations. Staff in the haemodialysis units and  pathology specimen reception were informed of the relevant codes to ensure samples are booked in correctly.

Benefits to environmental sustainabilityThe annual costs of printing 20,000 sheets of A4 paper (calculated using Hewlett-Packard's online tool) are:

  • Energy 563 kWh
  • Paper: 100kg
  • Energy & paper CO2 emissions: 380kg CO2
  • Energy & paper costs: £120

Doncaster Royal Infirmary

To reduce paperwork and filing backlogs, to free up clinical and administrative time, to reduce the risk of important results (eg microbiology reports) being missed and to reduce costs associated with printing.

Dr Ian Stott, Consultant Nephrologist & Assistant Clinical Director, ian.stott@dbh.nhs.uk, 01302 366666

Remote CKD monitoring as part of a Disease Management Program

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By: Sheffield Teaching Hospitals NHS Foundation Trust

These are still early days but generally patients and staff have responded very positively as people can receive care closer to home without losing touch with secondary care.

CKD management is predominantly data-driven. Considerable IT infrastructure is already in place that has enabled a remote CKD monitoring service for patients in Sheffield enabling devolved, patient centred care. A future renal database is likely to be able to increase the sophistication of such a disease management program. The start-up costs for such a model mainly consist of a salary for one clinical nurse specialist with modest consultant nephrologist support.


Current model of CKD care in Sheffield

The Sheffield Kidney Institute (SKI) in collaboration with primary care has introduced a number of measures to improve the recognition and management of chronic kidney disease (CKD) in the community whilst ensuring referrals to secondary care are ‘managed’ in an appropriate way.

These include:

  1. Online guidelines covering both the referral and management of CKD in primary care.
  2. Online educational package covering the management of CKD in primary care.
  3. Allocation of 1 PA of consultant time to screen referrals and advise GPs about which patients can be managed in primary care with appropriate management plans. Since the start of this service in 2006 approximately 30% of referrals from primary care have been dealt with through advice and guidance thereby avoiding unnecessary trips to secondary care. This service meets a key UK Renal Association standard that renal units should provide a non-visit based advisory service for primary care.
  4. In addition to the paper-based system above secure, electronic, consultant lead advice and guidance is available to primary through both the Choose and Book system as well through email via an nhs.net account.

Further to these measures, the SKI has identified a group of patients with CKD who currently remain under specialist kidney care but who could be effectively managed in primary care, with specialist support. These are patients with stable/slowly progressive but advanced CKD, who require regular biochemical and blood pressure monitoring, or who require specialist anaemia management.


The problem

Although the number of patients discharged to primary care has increased significantly, discharge rates from secondary care may be limited by concerns about whether patients can be reliably locked into a disease management programme in primary care. Indeed there is data to support such concern. For example the variability in prevalence of CKD by practice within Sheffield PCT ranges between 0% and 9.8%. Whilst some of this variation undoubtedly reflects practice-population demographics it is likely that systems for identifying and monitoring CKD varies between practices. Similarly, only 65% of patients in Sheffield PCT achieved the combined QOF indicators of being on a CKD register and attaining target blood pressure.


Proposed model of care 

We aim to develop the renal database (Proton) at the Sheffield Kidney Institute (SKI) to allow remote monitoring of patients with CKD. This is being done at the moment with the Sheffield Central Consortium of GP practices.

The key changes we have implemented are:

  1. Clinician-led CKD-Disease Management Program (CKD-DMP) specifying frequency of laboratory and blood pressure testing with individualised targets for care.
  2. All patients suitable for CKD-DMP to have bloods taken in primary care and self-monitor blood pressure or have blood pressure taken in GP surgeries
  3. To utilise a CKD nurse specialist to manage the remote data, liaise with patient and primary care physicians to replace clinic visits with a tele-consultation, reviewing clinical data with patient whilst maintaining care as set out by treatment targets in CKD-DMP.

Which personnel were involved?

CKD specialist nurse and consultant nephrologist in secondary care. Practice nurse in each surgery who acts as CKD link for specialist nurse

What was the timeframe?

Pilot started within 6 months of agreement between primary and secondary care.

Has the initiative been implemented elsewhere, before or since?

Not to our knowledge, though Bradford does have a well developed e-consultation service. This is different, being a remote monitoring and management service for chronic disease.


Sustainability benefits

The introduction of remote monitoring with tele-consultation has the potential to improve the targeting of specialist care resources (financial and environmental) to deliver the maximum value to patients.  By involving patients in self-monitoring, the model could potentially enhance patient empowerment in the management of their care, while reducing the need for travel as services are provided closer to home. 



No capital costs were required as the lab data already uploads data onto the renal database. Resource required in terms of specialist nurse time, consultant time and practice nurse/GP time

Dr Arif Khwaja, Consultant nephrologist, Arif.Khwaja@sth.nhs.uk

Pilot Study of a Kidney Patient Results Monitoring Service

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By: Royal Cornwall Hospitals NHS Trust

95% patients were happy with the way they received results. 86% patients felt that having blood tests taken at the surgery saved them time, money and the stress of travelling to hospital

£12,160 (Actual)

760kg CO2e (Estimated)

The renal department at the Royal Cornwall Hospitals NHS Trust conducted a ten month pilot study of a Kidney Patient Results Review Monitoring Service from June 2011 to March 2012. Patients with chronic kidney disease (CKD) III and IV were managed in primary care with secondary care supervision of blood results. Funding was offered via the Southwest Peninsula Network to set up a ‘virtual’ CKD clinic. Our team took up this opportunity, recognising the particular benefits in Cornwall, where rural patients currently travel long distances. The lead consultant was Dr. Rob Parry, supported by PRMS nurse, Mel Geall.The model successfully reduced the number of patient visits to renal outpatients, saving on patient time and travel, without compromising care.

Benefits to environmental sustainability

During the pilot, a total of 135 patients came under the review service, 119 of them were reviewed, with 95 clinic visits being saved. Mileage between the patients’ homes and the hospital where they attended their renal outpatient clinic were calculated using the ‘RAC Routeplanner’ website. A total of 2,020 miles were ‘saved’ resulting in a saving of 2020 miles x 0.37604 kgCO2e per mile* = 760 kgCO2e

It is also worth noting that some patients would be travelling to their appointments by ambulance or hospital funded transport.Two patients, who live on the Isles of Scilly, used to be flown by helicopter for each visit.

* total GHG conversion factor for medium cars using unknown fuel, taken from Annex 6 (Passenger Transport) of Defra 2012 greenhouse gas conversion factors for company reporting, available from: http://www.defra.gov.uk/publications/2012/05/30/pb13773-2012-ghg-conversion/)

Cost benefit

Costs: The pilot had funding for 1 day/week Band 6 specialist nurse and 2 hours/week consultant time (approx. £10,000 in total).

Savings: 175 tests were reviewed remotely, saving 95 clinic visits at a tariff of £128* = £12,160.

* 2011-12 PbR tariff for follow up attendance in nephrology, single professional

To see if carbon and patient time and money could be saved without compromising care


Patient numbers in the survey have been limited due to the limited time frame of study.

Mel Geall, PRMS Nurse, Mel.Geall@rcht.cornwall.nhs.uk

Reverse Osmosis Waste Water Recycling

By: Countess of Chester Hospital NHS Foundation Trust

Water saving: 1,460,000 litres / year

£3,144 (Estimated)

116.48kg CO2e (Estimated)

The Chester Green Nephrology Local Representative has led the development of a business case to enable the haemodialysis unit to recycle its 'grey' reject water produced by the reverse osmosis plant, which provides the purified water for dialysate. The plant runs for 123 hours per week, producing between 8.7-14.2 litres litres waste water per minute, just under a quarter of the annual water consumption within the Trust. If the project is implemented, the water will be stored and used for a regeneration of the carbon filters within the treatment plant, number of toilets, a sluice area, and a laundry area located in the renal outpatients department.

The project has been inspired by a previous Green Nephrology case study which was presented at the British Renal Society conference in 2010. Following this, the Chester Green Nephrology Local Representative, Elizabeth Critchley, proposed the introduction of waste water recycling to the carbon reduction team in Chester, who showed a keen interest. The calculations for water savings have been made in conjunction with a local water company, which has also given a a quote for the works.

Other people who have been approached within the Trust include the Renal Unit Manager, the EBME manager (responsible for RO plant maintenance), and the Estates department. The business case has now been submitted to the Trust carbon reduction team, who are supportive and will present it to the Board.

The water company undertaking the future works will be responsible for fitting the water tank, piping and connections to the plant room, roof space, toilets, sluice and laundry area. This work will be performed overnight and on Sundays when the plant is not being used, to eliminate any risk to the water pressures during operational times as this could pose unnecessary risk to patients on dialysis.

Benefits to environmental sustainability

The forecasted water saving is 4,000 litres per day 1,460 cubic metres per annum. Daily saving usage:

  • Water Reused by Carbon Filters - 1 backwash/day = 900 litres/day
  • Water Reused by Softeners - 2 regenerations/3 days = 500 litres/day
  • Available water for washing machines and toilet flushing = 2,600 litres/day

This amount equates to an approximate reduction in carbon emissions of 0.11648 tonnes CO2e per annum*.

Conversion factors used:

Water supply: 0.39 kgCO2/m3 - figure supplied by Welsh Water the Trust current water supplier

Sewerage: 0.17 kgCO2/m3 - figure supplied by the Environmental Agency

Financial benefits

The Trust will also make a financial saving of

  • Tap Water: £1370.79 per annum (£0.9389 per m3 of water)
  • Sewerage Services: £1773.17 per annum (£1.2145 per m3)
  • Total Annual saving = £3143.96

The Trust will be making a financial investment of £11,030, therefore the retrofit will have paid for itself within 3 years 6 months.

Wychwood Water Systems Ltd


Barriers have been encountered, which are inevitable in a project of this size. The sewerage company could not give the total carbon emissions for removing and treating 1 cubic metre of water therefore his calculation was taken from the Environmental Agency. The number of people and departments involved has been a challenge, since all areas that will be affected by the disruption, equipment and planning must be informed and consulted. The responsible person being on maternity leave has also contributed to delays in completion of the business case for consideration by the Trust board.

Elizabeth Critchley , Renal Unit Deputy Manager, elizabeth.critchley@coch.nhs.uk, 01244 365705/363705

Lighting Project

By: Bradford Teaching Hospitals NHS Foundation Trust

Additional benefits include an improvement in measured lighting levels and reduced maintenance costs as the new light fittings have a longer life span. An informal post-evaluation survey has shown that staff are happier with the increased levels of lighting. Apart from an improved working environment the project contributes to the achievement of the Trust's sustainable development goals and a redution in its climate change levy.

£612 per year (Estimated)

2.3 tonnes CO2e per year (Estimated)

The renal service decided to invest the full value of a BJRM Innovation in Renal Medicine Award 2011 prize (£5,000) in a  greener healthcare energy saving initiative. Following a site survey of the renal unit, the lighting project was chosen as the most appealing in terms of delivery, risk and savings. The survey revealed that the fluorescent light fittings were of a 'T8' type, whose energy consumption can be up to two times that of a modern 'T5' light fitting. Existing luminaires had started to degrade and could not produce all the expected light from the fluorescent tubes. Following a consultation exercise with  renal unit staff, a plan was agreed to install 'T5' light fittings. A total of 85 light fittings were changed in the Renal unit offices and wards.

The project was part of an on-going collaboration between the local Green Nephrology Champion and the Trust Estates department. The feasibility study, survey and business case were carried out by Mr Nsipa Siwale (Energy Manager). Activities included risk assessments, product selection, tendering and project management. Departmental support and funding was provided by Dr John Stoves. To minimise risks and disruption to staff and patients, most of the work was carried out after normal working hours.

Benefits to environmental sustainability

The annual operating hours for lighting in the Renal unit are 3,000 hours. The average energy saving per individual light is 36 kilowatt hours per year. Based on a greenhouse gas conversion factor of 0.58982 kgCO2e/kWh*, the project will save 11.5 tonnes of CO2e over 5 years.

* “All-scopes grid rolling average” emissions factor for electricity consumed (2010), Table 3c, Defra 2012 greenhouse gas conversion factors for company reporting

The main aim of the project was to reduce carbon emissions. The consultation exercise also revealed the need to improve levels of illumination in the unit, for example in the rooms used by technical staff.

The contractor for the project was JA Richardson Ltd, an experienced contractor who has undertaken several jobs successfully at the Trust with an excellent knowledge of the Trust and good Health and safety track record in the execution of similar projects.

Nsipa Siwale, Energy Manager, nsipa.siwale@bthft.nhs.uk

Retrofit of Heat Exchangers to Dialysis Machines

By: Newcastle Upon Tyne Hospitals NHS Foundation Trust

Reduced electricity bills for home dialysis patients

£327.60 - but likely to increase in Winter (Estimated)

1.207 tonnes - but likely to increase in Winter (Estimated)

Heat exchangers have been retrofitted to all 21 BBraun Dialog+ Dialysis Machines for patients on home haemodialysis. The decision was taken to prioritise retrofit of home haemodialysis machines after analysis of temperature changes and power consumption in the home and dialysis unit settings. The colder incoming water in patients' homes in Winter, as compared with the water temperature in the dialysis centre, resulted in increased power consumption over all and greater energysavings from inclusion of the heat exchanger.

Benefits to environmental sustainability

Estimated energy/CO2 savings

Energy savings were estimated by comparing a standard cycle on a machine with heat exchanger to one without. Results in the dialysis unit showed 5.2 kWh vs. 4.7 kWh (with heat exchanger), a saving of 0.5 kWh per treatment, or approx. 10%.

However, electricity usage was almost 3x higher for a treatment at the home of a home-dialysing patient, where the incoming water temperature was 5C, as compared with 10-22C in the dialysis unit. Power consumption from the WRO and HD without heat exchanger was 14.05 kWh. Energy savings in this setting would be expected to be greater. Even a 10% saving would save 1.4kWh per treatment – 218.4kWh per year.

Actual savings to date

Initial recordings have been taken in the summer months with an incoming water temperature of approx. 18C. Under these conditions, retrofitting of the heat exchangers has reduced electricity consumption by 0.625kWh per treatment. For a typical patient on 3 treatments per week, if the energy saving remained constant, then total energy savings would be 0.625kWh x 3 x52 = 97.5 kWh. Carbon savings would be estimated as 97.5 x 0.58982* = 57.5 kg CO2e per year per machine, or 1.207 tonnes CO2e for all 21 machines.

However, energy savings are likely to increase in winter with lower water temperatures in patients' homes.

Additional Benefits

The 21 home dialysis patients will benefit from reduced electricity bills. This cost saving may in future be passed onto the renal service through a commensurate reduction in the financial support given towards patients' utility bills. At a standard domestic tariff of £0.16/kWh, the 0.625 kWh electricity saving equates to a cost saving of approx. 10p/ treatment, translating to £15.60/year per machine, or £327.60/year for all 21 machines. However, total energy consumption and energy savings from the heat exchangers are expected to increase in colder weather.

* GHG emission factor for electricity consumed (2010 grid rolling average), taken from 2012 Guidelines to Defra / DECC's GHG Conversion Factors for Company Reporting (Table 3c)

Details of Implementation

Following contact from the Green Nephrology programme, highlighting environmental and cost savings achieved by retrofit of heat exchangers in Kent, Dr Suren Kanagasundaram (Renal Consultant and Newcastle Green Nephrology Local Representative) asked the renal technicians to investigate the business case for retrofitting heat exchangers locally.

45 machines were found to be suitable for retrofit. Because of the greater energy savings in the home setting and the availability of funding via the home dialysis conversion budget, the decision was taken to prioritise retrofit of all 21 home machines.  

The cost (approx. £4,700 (£223.70 per machine, including £7.50 labour costs)) was found from the home dialysis conversion budget. 

Electricity energy saving in patients homes – with both environmental and financial benefits.


The project was shortlisted for the Green Nephrology Awards 2012. The PDF award entry poster may be downloaded from here.

Pico Thermocouple data logger, K Type temperature sensors, Pico Software (for monitoring and recording data)
Kevin Gibbs, Lead Dialysis Technician, Kevin.Gibbs@nuth.nhs.uk, 0191 2448614

Baling and Recycling of Bottles & Cardboard

By: Newcastle Upon Tyne Hospitals NHS Foundation Trust

£7,384 net savings (Actual)

85.2 tonnes CO2e (Estimated)

The Renal Unit produces huge amounts of waste plastic and cardboard during its clinical activities. In order to recycle this waste the Trust installed two new pieces of equipment. A cardboard baler was installed to service the whole Freeman Hospital site in March 2011, which allowed the Renal Unit’s cardboard to be baled and recycled. In November 2011 a smaller twin baler was also installed to crush and bale the segregated 5L acid bottles from each renal dialysis session. Cardboard and plastic bottle recycling has increased by over 90 tonnes and savings of over £7,000 have been achieved.

The project was initiated by consultant nephrologist, Dr Alison Brown, and modern matron, Julia Harding. Using the commitment shown by the renal department, the Trust Waste Officer was able to justify a business case and gain Executive approval.

Equipment comprises a Static Vertical Mill Sized Baler (MX600) on long term rental for cardboard, and a twin chamber compact baler (Compact 75) on two-year rental for dialysis 5L plastic bottles. Baled cardboard and bottles are collected by SITA UK (the Trust's general waste contractor).


Environmental Benefits

An estimated 12 tonnes of plastic bottle waste is produced by the renal department each year.  Recycling all of this will save approximately 3.168 tonnes CO2e per year (1).

The renal unit has also been contributing its flattened cardboard to the main Freeman Hospital cardboard baler.  Approximately 100 tonnes of cardboard waste is produced annually and recycling this saves an estimated 82 tonnes CO2e per year (2). Unfortunately we are not able to break this down to the specific amount of cardboard produced by the Renal Unit as all areas of the hospital feed into the main cardboard baler. 

Total carbon savings from recycling of plastic and cardboard are therefore approximately 85.2 tonnes CO2e per year.

Importantly, recycling materials also reduces the need for virgin resources for new products. Although the benefits of this are hard to quantify, we know that increasing the recycling of resources instead of just disposing of them makes sense.

Furthermore, the compaction saves on CO2e emissions from large waste vehicle movements, since the much smaller volumes can be more easily stored and therefore collected less frequently. 

(1)This is based on -230 kg CO2e per tonne of plastic recycled vs 34 kg CO2e per tonne of plastic sent to landfill (Annex 9, DEFRA 2011 Greenhouse Gas Conversion Factors for Company Reporting) 

(2) This is based on -240 kg CO2e per tonne of cardboard recycled vs 580 kg CO2e per tonne of cardboard sent to landfill (Annex 9, DEFRA 2011 Greenhouse Gas Conversion Factors for Company Reporting) 


Financial Benefits

The financial savings are summarised below:

Waste Type

Predicted Annual Weight of Waste

Previous Total Disposal Costs

New Annual Baler Rental

New Disposal Costs

New Total Annual Costs

Net costs

Plastic Bottles





















To reduce the environmental impact and cost of waste disposal. The project was inspired by an early Green Nephrology case study: http://map.sustainablehealthcare.org.uk/heart-england-nhs-foundation-trust/diversion-waste-recycling-stream-through-use-baling-machines .

SITA UK (long term lease of cardboard baler; collection and rebate for baled cardboard and plastic). Local firm ATK Equipment (2-year lease of plastic bottle baler).


The project was the winner of the Green Nephrology Awards 2012; the award entry poster can be downloaded here.

£4,376 (annual rental costs for balers)

Initial barriers included problems with siting the balers (H&S, fire risk, electrical enabling works, delivery, access etc) and porter buy-in for carrying out the baling tasks. All barriers were overcome through effective communication and options analysis. Beneficial drivers (cost and environmental savings) allowed us to convince all parties that it was the right thing to do. The barriers did place time delays on the project initiation but once approved and installed the successes have demonstrated it was worthwhile.

Problems that arose following implementation have mainly focused on contamination of the bottles resulting in residue on the baler (and difficult working conditions for the porters). This was overcome by showing renal staff the importance of rinsing and emptying all bottles before disposal. We also arranged a full service and clean of the twin baler and this issue hasn't been raised since. To date there have been no issues with the cardboard baler.

James Dixon, Trust Waste Officer, James.dixon@nuth.nhs.uk, 0191 282 1543

44:1 Haemodialysis Concentrate Solution

By: East Kent Hospitals University NHS Foundation Trust

Carbon savings from transport of smaller volumes of concentrate. In addition, using a 4.7ltr can rather than a 6ltr can will mean a reduction in manual handling effort for the renal unit staff transporting the concentrate solution from the store to machine. Also, a pallet holds 128 cans of 44 to 1 concentrate compared to 90 cans of the larger 34 to 1 concentrate can thus reducing the number of pallet movements and optimising storage area in the renal unit.

£0 (Actual)

16.22 tonnes (Estimated)

During haemodialysis, creation of the dialysate fluid requires a concentrated acidic solution of known constituents to be drawn into the machine. This solution is diluted with a set volume of purified water from a reverse osmosis unit to achieve the correct concentration. Our Trust had previously used cans of acidic concentrate which require a 34:1 ratio of dilution, i.e. 1 part concentrate to 34 parts water. This 34:1 solution is supplied in a 6 litre can. The same final composition can also be achieved using an alternative acidic solution with a concentration of 44:1 after some minor technical adjustments to the dialysis machine. This 44:1 solution can be supplied in a 4.7 litre can. The can size of each of the solution concentrations reflect a reasonable diluted volume to comfortably supply a 4-4.5 hour dialysis treatment.

Details of implementation

As the four most commonly used solutions were not available in the smaller container, the manufacturer BBraun was approached to develop the specific solutions with a 44:1 concentration in the required size container for the same cost and to provide advice on the minor technical changes needed to the dialysis machines. 

The trust procurement and supplies department were consulted to arrange new product codes to be allocated to the new items when bulk ordering. 

The dialysis machines’ settings were subsequently adjusted accordingly by the trust renal technicians to allow safe operation with the higher concentrations of solution.

The Higher concentration (44 to 1) solutions have been available for some time, although there are still a significant amount of treatments around the UK using the 34 to 1 can option. Switching to the 44 to 1 concentration cans is a relatively easy process at negligible cost and may be a more simple method of reducing concentrate solution storage without procuring and maintaining a more costly central acid delivery system.

Higher concentration dialysis solutions (44 to 1) are also available from other manufacturers and can be used in alternative brands of dialysis machine.

Benefits to environmental sustainability: Reduction in greenhouse gas emissions from road transport

The concentrate is manufactured and transported by road from Glandorf, Germany to Sheffield and from Sheffield to Kent. An estimate of the carbon savings from transporting smaller volumes can be made as follows:

Reduction of concentrate used per treatment = 6 to 4.7 litre can = 1.3 litres

Reduction of concentrate used daily in the Trust = 200 x 1.3 litres = 260 litres

Reduction of concentrate used annually = 260 x 312 days = 81,120 litres

Thus approximate weight each year = 81.1 tonnes

Glandorf to Sheffield = 960 km

Sheffield to Canterbury = 374 km

Total distance= 1334 km

Approximate annual reduction in greenhouse gas emissions from road freight:

= 0.14993 * x 81.1(tonnes) x 1334(km) = 16,220 kg CO2e / year = 16.22 tonnes CO2e / year

(* 2012 Guidelines to Defra/DECC's GHG Conversion Factors for Company Reporting (Annex 7, Table 7e))

This cost neutral initiative is primarily to reduce the burden to the environment in transporting dialysis consumables.



Project entered to the Green Nephrology Awards 2012 - pdf poster available to download from http://sustainablehealthcare.org.uk/green-nephrology/resources/2012/09/green-nephrology-award-entries-2012-posters-g-n

Fraser Campbell, Renal Technician, frasercampbell@nhs.net, 01622 225884